Drug dependence in the U.S.A.

Sections

INTRODUCTION
(a) Use of drugs
(b) Opiates
(c) Cannabis
(d) Hallucinogens
(e) Amphetamines
(f) Barbiturates and other sedatives
3. TYPES OF TREATMENT AVAILABLE
(a) Voluntary treatments
(b) Ancillary treatments aimed primarily at ensuring abstinence
(c) Ancillary treatment aimed at rehabilitation
Current treatment facilities in North America
Civil commitment
Hospital treatment
Out-patient maintenance of addicts
Methadone maintenance treatment
Use of narcotic antagonists
Treatment for persons using non-opiate drugs of abuse
Community care
Synanon
Daytop Lodge
4. EFFECTIVENESS OF TREATMENT PROGRAMMES FOR HEROIN ADDICTS (Task Force report review)
Possible new methods of treatment
Role of state local, public and private groups
5. DESCRIPTION OF SOME CENTRES VISITED
UNITED STATES
CANADA
6. SUMMARY
Reports quoted

Details

Author: Thomas H. BEWLEY
Pages: 13 to 30
Creation Date: 1969/01/01

Drug dependence in the U.S.A.

M.A., M.D., F.R.C.P.I. Thomas H. BEWLEY Consultant Psychiatrist, Tooting Bec Hospital, London

Based on a report prepared by the author under a fellowship from the World Health Organization to study drug dependence programmes with particular reference to the United States and Canada. It is published with the permission of the World Health Organization.

INTRODUCTION

This report was drawn up after a five-and-a-half week visit to the United States in September-October 1967 on a WHO fellowship.

An exact account of such a visit tends to be extremely repetitious and of limited value, with many paragraphs saying: "visited so and so", "discussed drug scene" "exchanged reprints" and so forth. An alternative method of presentation is to review the subject relying entirely on published reports and ignoring the actual trip and visits made. The author has aimed at a compromise between these two approaches. He has tried to give an account of the situation in North America and compare it with that in Great Britain. He has combined the accounts of places visited with many verbatim extracts from published reports. His idea was to give a more valuable account of drug dependence treatment and research programmes in the United States and Canada than would come from a straight report on the trip. For this reason a large portion of the report has been a scissors-and-paste extraction of other people's accounts of various projects. The original report, which was indeed not designed for publication, was prepared in such a way that it would be of use to anyone from the United Kingdom who was going to visit the United States and for this reason contained a list of names and addresses of people and places visited. For the purpose of publication, this has been omitted and the report has been slightly shortened by the removal of some repetitions and some personal opinions of the author, which would be out of place in a published report.

The author was able to visit ten cities spending about three and a half days in each of them (with a week in San Francisco). In all, he must have studied the work of about forty institutions and had discussions about drug dependence problems with eighty or more American physicians, psychologists and other scientists.

In this report he has been very much helped by many papers, reprints and reports which he collected on the visit. The Consultants' papers in the Task Force report on drug addiction from the report of the President's Commission" The Challenge of Crime in a Free Society" were particularly valuable. These have been used extensively, and are quoted verbatim at length, together with other reports when this seemed to give the most succinct and authoritative account of a project.

The report is in six sections:

  1. A comparison of the over-all situation in the U.S.A. and Britain.

  2. Attitudes to misuse of drugs and control measures.

  3. A survey of different types of treatment available in the U.S.A.

  4. The evaluation of effectiveness of treatment programmes.

  5. Brief accounts of some of the work at some centres visited.

  6. A summary of some over-all impressions.

  1. OVER-ALL SUMMARY OF THE SITUATION IN THE UNITED STATES COMPARED WITH THE UNITED KINGDOM

(a) Use of drugs

In the United States there has been a much longer history of drug dependence problems than in the United Kingdom and the size of the problem is very much greater. Like the United Kingdom, far and away the largest problem is alcoholism, with probably at least six million alcoholics, compared with three hundred thousand in the United Kingdom.

As my visit concerned the socially non-acceptable drugs I will not expand this here.

(b) Opiates

Opiate addiction in the U.S.A. has had a longer history than in Great Britain, morphine addiction probably starting after the Civil War, this changing to heroin at a later date, and the United States has never since been free of this problem. Estimates of the number of addicts to opiates, (now predominately heroin) vary, but the over-all number may be of the order of 60,000 to 100,000 such addicts with possibly 30,000 to 35,000 in New York City. This is very different from the United Kingdom where the numbers have risen from under 100 to between 1,000 and 2,000 between 1958 and 1968.

Opiate addiction in the United States appears to be more likely to be found associated with poverty, urban problems, failure of integration of negroes, Mexicans and Puerto Ricans. Narcotic addiction, particularly heroin addiction, is found more frequently in such groups. It is also found in the most poverty stricken slums in the larger cities.

Another difference between the two countries is the fact that heroin is illegal and the provision of a narcotic for ambulatory maintenance of a narcotic addict is looked upon as medically unsound and ethically unwarranted in the U.S.A. The heroin the narcotic addicts use in the United States is entirely obtained from the black market (run by criminals who smuggle narcotics into the country to sell them). In the United Kingdom addicts also first obtain narcotics on the black market but the black market is entirely supported by patients who are having more narcotics prescribed for them than they need, and who can thus sell the surplus.

Drug abuse problems in the United States have changed rapidly and this is something that is becoming increasingly familiar in Great Britain. For example, there was an apparent increase in adolescent heroin addiction shortly after the war in the United States and a similar one starting in 1960 in Britain.

Another interesting point that is worth noting is the very marked difference in dosage of drugs taken in the United Kingdom and the United States. The mean daily dose of the average New York heroin addict has been guessed at 80 milligrammes per day compared with 240 milligrammes per day for the British addict who is having pharmacologically pure heroin prescribed for him.

(c) Cannabis

With cannabis use there are more similarities between the two countries, in that this is a fairly new phenomenon in both. The smoking of cannabis in the United States appeared earlier, having started with the use of marijuana by Mexicans, spreading northwards later (in the United States). There are now many similarities in the groups who use cannabis in both countries, one being rather more intellectual (e.g. college students) and another recent immigrants and a third consisting of a larger number of people with deviant personalities (e.g. histories of juvenile delinquency or minor criminality).

Attitudes to the use of cannabis are the same in both countries, but more extreme in the United States with two vociferous lobbies stating either "this is a completely safe substance" or" it is an exceedingly dangerous drug." In theory, the death penalty remains on the Statute book in some states for the offence of supplying cannabis to a minor on two (or three) occasions. Another difference in the use of marijuana in the United States and the United Kingdom is that the use of the resin (or hashish) which contains more of the active principles, is very much commoner in Britain than in the United States.

(d) Hallucinogens

There are similarities between the two countries as far as use of hallucinogens is concerned, but in the United Kingdom the use of drugs such as L.S.D. is on a much smaller scale. In both countries this use first started in intellectual and university circles, with L.S.D. being the main agent for "taking a trip". It has now spread to other groups in the population, though it is still much commoner in the United States (particularly in universities and on the West Coast) than in the United Kingdom. The patterns of use appears to be very similar in both countries.

(e) Amphetamines

As far as amphetamines are concerned, their abuse also appears to be similar in both countries. It may begin when the drugs have originally been prescribed as appetite suppressants or for mild depression, and the person, for example, a middle-aged woman, becomes therapeutically dependent on them and has difficulty in stopping. The extent of this type of misuse is not known in either country, but it is probably quite large. Sometimes amphetamines and amphetamine-barbiturate combinations are stolen, or otherwise diverted from legitimate channels and then sold illicitly as "pep pills". These are taken in order to produce a feeling of euphoria and well-being and to stay awake, and the same groups of people in both countries appear to use them in this way (chiefly "spree" use by young people at weekends). There is very little hard information in either country on the extent of this use, or on its harmfulness.

The last way that amphetamines are increasingly widely misused, is very similar in both countries, that is they may be taken intravenously. There appears to have been quite a marked increase in this in the last year in both the United Kingdom and in the United States and some concern has been expressed particularly in San Francisco, about the dangers of this habit (which is also becoming increasingly common in Sweden). Septic complications, drug psychoses and inability to remain in a stable job are seen equally frequently in all three countries.

(f) Barbiturates and other sedatives

This group of drugs is widely misused both in Britain and the United States, but much less is known about barbiturates. It is extremely difficult to get any information about the extent of this misuse in either country, but the pattern in both appears to be similar. Probably far more of these compounds are being prescribed than is justified medically, and this has led to their increased use. The number of cases where persons are admitted to hospital following a self-administered poisoning by overdoses of a barbiturate or barbiturate-like drug have risen.

Barbiturate use as a method of suicide has increased in both countries, as have accidental poisonings, and almost certainly there is a large unknown group of people in both countries who have become dependent on the drugs. These would almost all have become dependent in the course of medical treatment, barbiturates first having been prescribed to allay anxiety or promote sleep.

  1. ATTITUDES TO MISUSE OF DRUGS

There does not appear to be very much difference in general attitudes to drug taking in the two countries, except that extreme views are much more likely to be found in the United States and this is reflected in the differences in laws in the two countries. In general, some individual States of the U.S.A. have drug laws that are more severe than Federal laws and in practice it would be possible for a person who was guilty of a drug offence to receive a different sentence depending on whether he was arrested by a Federal or a Local narcotics agent and appeared before a Federal or state court and was sentenced under Federal or state laws. In the United Kingdom there is only one legislature applying itself to a difficult problem, which arouses strongly held opinions, and at the same time about which there is little factual evidence.

The United States Congress passed the Harrison Act in 1914. Since that date, Federal control of narcotics has been in the hands of the Bureau of Narcotics which has recently been transferred from the Treasury to the Justice Department. One effect of the regulations based on this Act has been to cause many physicians to believe, until very recently, that it was virtually impossible for a doctor to prescribe a narcotic for an addict (except for relief of pain), though recently with the development of methadone maintenance programmes a breach has been made in this interpretation of the regulation. Again, as in Great Britain, marijuana has been controlled under the same Acts as opiates such as heroin and the regulatory agencies have dealt with it in similar fashion.

The major difference between the British and American methods of controlling narcotic addiction, are in the ways that the Acts controlling narcotics are implemented, the Acts themselves being (apparently) similar.

3. TYPES OF TREATMENT AVAILABLE

In a review of types of treatment available for narcotic addicts in the Task Force report on narcotic addiction various approaches were identified:

(a) Voluntary treatments

  1. Medical psychiatric. A number of hospitals admit heroin addicts, on a voluntary basis for detoxification, etc.

  2. Synanon type programmes. Several primarily non-medical programmes exist.

  3. Addicts Anonymous. A voluntary group modelled on Alcoholics Anonymous.

  4. Religious programmes. These rely on religion as a major motivation for abstinence.

(b) Ancillary treatments aimed primarily at ensuring abstinence

  1. Nalline testing. California and a few other programmes utilize periodic injections of nalline, a narcotic antagonist to test patients for evidence of re-addiction.

  2. Urine testing. Thin layer chromatography (and potentially other methods) can be used to examine the urines of addicts under treatment for the presence of opiates.

  3. Cyclazocine. This long acting narcotic antagonist can apparently successfully prevent even relatively large doses of heroin from having any effect.

  4. Methadone. A long acting opiate which if taken daily in a relatively large dosage provides a substitute addiction which also makes heroin taking ineffective.

(c) Ancillary treatment aimed at rehabilitation

  1. Individual psychotherapy.

  2. Group psychotherapy.

  3. Milieu treatment. Here structured settings are used as a treatment modality. At the Synanon end it can resemble intensive twenty-four hour group psychotherapy. At the minimal end it can consist chiefly of a drug-free environment which provides reasonable rules and regulations and some activities to keep patients occupied.

  1. Special living arrangements.

  2. Vocational rehabilitation. Since many addicts have never achieved any stable work role, training ex-addicts may be necessary to make them employable, or enable them to hold jobs which would be satisfying for hope of a better future.

  3. Family and social services. Work with the addict's family may be useful in correcting old and harmful inter-personal attitudes.

Current treatment facilities in North America

  1. Federal. At present the U.S. Public Health Service Hospitals at Lexington and Fort Worth provide chiefly in-patient treatment for voluntary and prisoner addicts and they lack after-care programmes.

  2. State. There is a major state hospital programme in New York where the number of beds for addicts are being rapidly increased in state hospitals and special facilities are being organized under the so called Rockefeller Law of 1966. There had been approximately 2,000 first admissions with the diagnosis of drug addiction to all United States, state or county mental hospitals in 1963, one third of these in New York state. California has a large correctional programme with a prolonged in-patient care at the California Rehabilitation Centre in Corona which serves the whole state and has almost 2,000 resident patients.

  3. Cities. Only New York city appears to have any number and variety of treatment facilities. Until recently Chicago had no voluntary treatment programme except St. Leonard's House (medical in-patient withdrawal could be obtained only through imprisonment with treatment from Bridewell Hospital, a unit run by the Cook County Jail). However, the Illinois State Narcotics Board is now setting up an active programme.

  4. Canada. Programmes vary from province to province, both British Columbia and Ontario have been utilizing maintenance methadone treatment with some reported success. In Vancouver, this drug is given to older addicts for several months to ease the transition to abstinence. The Canadian Medical Association concluded that methadone could be used for gradual withdrawal or prolonged maintenance, and recommended a series of safeguards to be followed by any physician attempting maintenance therapy to ensure that his was the only source of methadone for each patient. The programme of the Alcoholism and Drug Addiction Research Foundation in Ontario has several interesting features.

  1. Methadone-buffered withdrawal from opiates si carried out on an out-patient basis.

  2. No direct psychotherapy is attempted early in treatment.

  3. Patients adjusting poorly after abstinence has been achieved, are tried on maintenance methadone (30 milligrammes per day).

Civil commitment

There are at least four types of civil commitment for addicts.

  1. Commitment on request of non-criminal addicts.

  2. Involuntary commitment of non-criminal addicts.

  3. Commitment on request or consent of criminal addicts.

  4. Involuntary commitment of criminal addicts.

There has been a lot of comment about the involuntary commitment of non-criminal addicts, the main complaint being that this constitutes "cruel and unusual punishment ". The argument is that commitment is a subterfuge "holding out the promise of a known method of treatment or a reasonable prospect of cure which does not exist ". Despite this an interesting development recently has been the starting of a number of civil commitment programmes. In effect these started first in California in 1961 after a court ruling that previous provisions which sought to make criminal the mere fact of "being an addict, as opposed to possessing or selling drugs" was unconstitutional. Under further legislation passed at that time, a person found guilty of a misdemeanour or non-violent felony and identified as an addict can be committed for up to seven years to the California Rehabilitation Center Programme which is administered by the Department of Correction. Out of this period, rather more than the first year is on average spent in a closed institution, where the emphasis is on counselling, work rehabilitation and exploitation of a therapeutic milieu. Following this, the addict is then placed on parole with strict supervision and routine chemical testing of the urine and this is associated with nalline tests. A breach of parole (for example a positive urine test or nalline test) results in return to custody. In 1966, under the Federal Narcotic Rehabilitation Act, similar legislation was put into effect in all states and in 1967 New York started a similar elaborate programme of state civil commitment.

There is no doubt that in the United States, feelings about narcotic addiction are very much stronger than in the United Kingdom, and yet there is little agreed fact on which to base assertions about the value of different types of programme. At present there is no evidence that the harsher legal measures in the United States either prevent addiction or help in the treatment of the individual.

Drug dependence in the U.S.A. 17

On the other hand, in the United Kingdom, a more liberal climate of opinion has not prevented a very marked and rapid increase of narcotic addiction and there is no evidence either that prescribing narcotics for addicts is in any way a better policy than the American one. Another interesting point that emerges is that in both the United Kingdom and in the United States, efforts are being made to have more severe penalties for peddlers than for addicts, but in practice in both countries this has been unsuccessful, since frequently the addict and the peddler are the same person. In practice in the United Kingdom there is no theoretical difference in the penalties for possession but, since courts have a wider discretion in the penalties that they give, in a case in which the amount of the narcotic possessed gives ground for suspicion of peddling, the punishment is more severe.

It is also interesting that a very large amount of work in the United States at present is based on a very small number of papers (for example, those by G. E. Vaillant) showing that punishment alone, or informal treatment alone, was relatively ineffective but a period of compulsory treatment followed by a period of licence was much more effective. Important conclusions are expected from a follow up by Vaillant of a hundred addicts discharged twelve years previously from the Federal Hospital at Lexington. Whether it is wise to start a programme costing many million dollars on the results of a follow-up of a small number of patients must be questioned.

Hospital treatment

Until recently treatment opportunities for opiate addicts were largely restricted to the two Federal Narcotic Hospitals at Lexington, Kentucky and Fort Worth, Texas. Lexington had been established since 1935, both voluntary patients and prisoner patients being admitted. Although the majority of admissions are of voluntary patients these do not stay as long as prisoner patients, and at any time the majority of patients in the hospitals are prisoner patients. The recommended length of stay for a voluntary patient is 5 months but most leave sooner, and against medical advice. There is no effective after-care or supervision in the community except in the case of a prisoner patient who has been granted parole. Recent surveys with long-term follow-up have shown that the majority of patients from these hospitals relapse, but with the passage _of time, use drugs less often.

With the exception of the new treatment centres in New York which appear to be starting on a wave of slightly uncritical enthusiasm, the general impression of American hospitals where drug addicts are treated is that doctors are now questioning the value of their efforts and that apart from providing a period of temporary incarceration, or withdrawal of drugs, or treat- ment for secondary complications, they have little to offer the addict. It is partly this feeling that appears to have led to a change in function of the two U.S. P.H.S. Hospitals at Lexington and Fort Worth from service hospitals (the former also having an addiction research unit) to being research units directly under the control of the National Institutes of Mental Health.

Out-patient maintenance of addicts

It is interesting that the experience in the United States between 1919 and 1923 when heroin was prescribed for addicts was generally considered to be a failure though it is virtually impossible to find any clear cut account of what happened at that time. It would appear that many of the clinics merely handed out drugs with little notion of what they were doing and without follow-up so that they could almost as well have had heroin dispensed from slot machines. From the medical point of view, this was generally considered to be unsatisfactory and the Bureau of Narcotics felt that it was quite undesirable. On the other hand, there is absolutely no evidence that if this had continued indefinitely there would be any more addicts today than there are at present. Nor is there any evidence of what might have happened with controlled prescribing. This appears to be a subject that produces strong feelings without much evidence to support them. The most recent development here is the use of methadone for maintenance. This appears to be a theoretically very much more rational approach to treatment than any that have been suggested up to the present. In the first instance, the drug can be dispensed so that the addict can have a regular dose. Secondly, it is a long acting drug and can be taken once daily. Lastly it does not have to be taken by injection, and the problems arising from unsterile self injection are thus avoided. What appears to be quite as interesting as the methadone maintenance programme itself is the extraordinary degree of strong views about the programme, varying from the missionary enthusiasm of some proponents of the programme to the equally strong denigration by others. One of the striking features of this controversy is the limited knowledge of some medical and lay experts who are willing to pontificate about the subject at the drop of a hat.

Methadone maintenance treatment

This was started by Dr. V. Dole and Dr. M. Nyswander of New York, and was used by Dr. J. Jaffe at Albert Einstein Hospital and later in Chicago and also various other groups of workers now in Canada and the U.S.A. It consists of two variants:

  1. Prolonged maintenance on relatively high dosages of methadone up to 80 to 100 milligrammes a day in a single supervised daily dose of liquid medication. At this level, self-administration of even relatively large amounts of illicit heroin have little effect. The patient is thus "protected" against illicit heroin abuse.

  1. Gradual out-patient withdrawal with methadone being administered in slowly decreasing doses for several months but leading reasonably directly to total abstinence. This method is more used in Canada.

As managed by Vincent Dole and Marie Nyswander the programme has a certain missionary zeal and this may be partially responsible for their claims for almost universal success. It should be noted that the methadone is accompanied by a good deal of supportive contact and pressure towards rehabilitation. It will be interesting to see whether other units will have similar success. Dr. Dole does not deny that his patients may abuse some non-opiate drugs but claims that they take no drugs which they had not taken prior to treatment.

Treatment at the Metropolitan Hospital in New York City is also testing methadone maintenance but Professor Freedman found the drug less free of side effects and less enthusiastically received by his addict patients than those of Dr. Dole. Less than half his patients could be considered successes. Dr. Jaffe in a much smaller group of addicts, with repeated failures in other programmes, had found the maintenance opiate administration useful when combined with a monitoring of drugs by urine testing, and supported by a firm pressure upon the patient to get a job and lead a socially responsible life.

Use of narcotic antagonists

Cyclazocine treatment

This long acting opiate antagonist (similar to nalline), developed as a drug by Winthrop Pharmaceuticals and assessed as a potential treatment for drug addiction by the National Institute of Mental Health Addiction Research Center at Lexington, was first tried as a treatment for addicts on a pilot basis by Jaffe and by Freedman in New York. It is the first narcotic antagonist that has been widely used, and it is at present being used in Chicago.

Treatment for persons using non-opiate drugs of abuse

There are no special treatment facilities specifically designed to serve individuals dependent on non-opiate drugs and most programmes are restricted to opiate addicts. An exception to this is the free medical clinic in the Haight-Ashbury district of San Francisco which provides treatment for secondary complications (of multiple drug use) as well as ordinary medical care.

Community care

Although community care is very much the centre of most recent planning in American psychiatry, this has been less marked in the field of drug addiction, with the exception of the work of Dr. Efren Ramirez, which was started in Puerto Rico and which he now continues as co-ordinator of Narcotics Programmes in New York City. There are some very interesting parallels between his work and the work of the Addiction Unit in Birmingham, England, at All Saints Hospital in that the aim of the treatment in both cases is not to get patients into hospital to start belabouring them with treatment at an early stage, but rather to develop a therapeutic relationship with the patient while he is still in the community and at a later stage when he has practically finished treatment he comes into hospital and gives up drug taking. In Birmingham, the addict in the early stages of treatment has drugs prescribed for him. In the Ramirez type programme he merely continues to obtain them illicitly. The induction phase described by Dr. Ramirez as "a training process for future treatment" lasts two to three months and comprises street encounter, day hostel programme and finally detoxification. The Birmingham programme consists of encounter, prescription of heroin and later detoxification. A difference in the two approaches is that in New York, Dr. Ramirez looks on the addict as the best person to initiate treatment, and by this he means the ex-addict, the person in the final stages of treatment or the person who has been successfully treated. This is not the case in the Birmingham programme- though in Britain there are still very few ex-addicts who might fill this role.

Synanon

Synanon, an ex-addict community with several facilities in California, has proved to be an effective way of organizing treatment. It has, however, discouraged ex-addicts from leaving Synanon and re-entering the larger community and has zealously maintained its separation from government programmes. Further, Synanon, after a rapid growth between 1958 and 1965 has now apparently stabilized its size at approximately 600 residents. Because of the nature of its programme, it is unlikely to increase significantly in size.

Daytop Lodge

This is an open voluntary treatment programme originally serving drug addicts placed on probation by the local courts of Brooklyn, New York. Technically it is a half-way house, but has a much more active treatment programme headed by an ex-addict, Dave Deitch, trained at Synanon. The lodge is staffed chiefly by ex-addicts; its major features are:

  1. The newly referred addict is made to fight his way in to the programme.

  2. Rigid high standards for behaviour in all areas is expected and enforced, by all patients.

Drug dependence in the U.S.A. 19

  1. The new addict is treated as a helpless child first, but gradually moves from menial to responsible jobs at the Lodge and finally to work outside.

  2. Vigorous, aggressive "gut level" group sessions are held frequently.

  3. More intellectual philosophic seminar sessions are also held. The similarity to Synanon is striking, the major difference being that the former is a purely voluntary private organization, while Daytop Lodge was supported by a National Institute of Mental Health Grant. It was also originally under court sponsorship. The Daytop Lodge programme now receives support from the City of New York and now also accepts voluntary admissions and patients from sources other than the Brooklyn Courts.

4. EFFECTIVENESS OF TREATMENT PROGRAMMES FOR HEROIN ADDICTS (Task Force report review)

There is agreement, based on a good deal of evidence, on a few statements about the outcome of treatments of heroin addicts.

  1. Methadone treatment during the acute withdrawal phase is safe, sound and reasonable and is superior to the use of non-opiates, tranquillizers and sedatives.

  2. The relapse rate is very high if there is simple institutionalization (medical or penal) and the released patient is then without aftercare or rehabilitation.

  3. Three classes of opiate addicts show a somewhat better prognosis for abstinence, independent of treatment.

  1. Medical addicts--patients becoming addicted in the course of treatment by physicians for real or functional physical complaints.

  2. Physicians or other professional addicts.

  3. Older heroin addicts.

  1. Enforced parole or aftercare leads to less readdiction or re-imprisonment than minimal or no aftercare treatment.

  2. Most heroin addicts do not co-operate well in formal dynamic psychotherapy or case work involving interviews of the sort ordinarily provided to middle class psychoneurotics.

  3. Most heroin addicts have a large array of needs and inadequacies over and above their use of narcotics. (No money, no place to live, no readily marketable job skills, low frustration tolerance, low interest in or experience with the usual activities and pressures of the world, usually difficult family situations, low motivation to solve any of these problems, and little trust in professional therapists.)

Given the above as a reasonably probable set of facts, it is interesting to note that programmes and therapies claiming substantial, if often undefined success, may be superficially very different. This applies, for example, to Synanon, Daytop Lodge, the California Rehabilitation Center, New York City's intensive parole system, methadone maintenance, cyclazocine antagonization, frequent urine testing safeguards etc., and yet all these approaches have several elements in common:

  1. They provide considerable outside pressure to the addict to stay off drugs.

  2. The addict is given reasonably frequent support by contact with the treatment agency.

  3. Some assistance or encouragement to get a job and a suitable place to live is offered by the agency.

Given all of the above elements a number of areas of disagreement yet exists as to the best treatment approach, and it covers:

  1. Aims of treatment: abstinence versus better social functioning.

  2. Voluntary versus involuntary treatment.

  3. The ultimate period of in-patient treatment: though intensive psychotherapy, sociotherapy, vocational rehabilitation etc. should enable the addict to do better, there is no positive evidence that this is the case.

  4. Treatment setting: are medical settings really superior to penal ones?

Possible new methods of treatment

  1. A cyclazocine-like drug with a much longer duration of action, three days to two weeks would be useful since the patients would have to come to the clinic less frequently.

  2. Formal conditioning theory could be extended as suggested by Wikler and Martin who consider that cyclazocine or similar treatment could be made more effective if the addicts tried heroin or similar drugs several times and got no effect, thus extinguishing the earlier conditioned positive response to the drug.

  3. As with alcoholism it is likely that addicts might benefit from better integration and co-ordination of the various medical social rehabilitation and welfare services available in most large cities.

  4. It is possible that the treatment of heroin addicts in non-addict settings, general hospitals, psychiatric clinics, or a doctor's private office might aid his separation from the addict culture. This possibility could be explored further.

Role of state local, public and private groups

At present in most places, more could be done in this respect. At least one agency should provide a strong comprehensive programme alone, or in collaboration with other agencies. Detoxification facilities should be available without the addicts having to be committed or convicted. It is probably desirable that both voluntary and involuntary programmes should be available (the latter being used for failures of the former). The present state of availability of several different treatment programmes seems preferable to a simple rigidly fixed programme.

Dr. Jonothan Cole (in Narcotics and Drugs Abuse, Task Force report) suggests that a comprehensive programme for a city with substantial drug abuse problems (500 new cases a year based on current knowledge) might include the following components and inter-relationships: a major central treatment facility integrated into a medical school and a community mental health centre. This should provide in-patient detoxification for about half the city's voluntary committed patients, plus longer term in-patient intensive treatment for selected treatment-resistant patients from all over the city.

5. DESCRIPTION OF SOME CENTRES VISITED

(A selective account of some typical centres visited which are examples of various approaches used. This is not exhaustive to avoid needless repetition.)

UNITED STATES

New York

The problem of narcotics addiction in New York City is endemic, and it is of epidemic proportions. The U.S. Treasury Department reported that in 1964 there were 56,000 addicts in the United States and of those approximately 35,000 by the most accurate estimate, were believed to live in New York City. An average of 9,000 individuals are estimated to become newly addicted each year. The problem is city wide though expectedly it is most devastating in those areas where poverty is chronic, and despair is a habit.

In 1914 the Federal Harrison Act was passed establishing the basic machinery for the regulation of illegal drug traffic in the United States and thus became a means for the prohibition of all use of opiates for nonmedical purposes. From then, through the mid fifties, the problem of drug addiction was largely in the domain of law enforcement agencies and the drug addict was seldom treated by private physicians or in civilian hospitals. The arrested addict was remanded to prison or to the U.S. Public Health Hospitals in Lexington, Kentucky and Fort Worth, Texas. Non-arrested addicts could voluntary commit themselves to treatment in one of these two hospitals.

Most studies put relapse and recidivism rates after treatment in such institutions at 80 to 90 per cent or higher. Until the 1950s the response in New York City was no more significant than that in other parts of the country, but its problem was more severe.

In 1957 and 1958, independently and almost simultaneously, private programmes to deal specifically with narcotic addiction were initiated. Interestingly enough, these programmes were not begun by welfare agencies or medical facilities, but by individual ministers or church groups, because their founders felt that "something had to be done to help drug addicts ". There was no systematic knowledge available to indicate how the addict should be helped, but this did not deter the organization of programmes based largely on providing the addict with series of services, food, lodging, clothing, job referral and in some cases money.

These programmes (with others consolidated in the New York Neighborhoods Council for Narcotics Addiction) lobbied for the provision of treatment facilities by the City to meet the urgent need, and in 1959 the City opened a narcotic addict service at a hospital, where addicts could voluntarily go for treatment. None of the patients was court committed.

In 1962 the Metcalfe-Volker Act was passed by New York State, providing for the State Commissioner of Mental Hygiene to formulate comprehensive plans for the long range development of adequate services and facilities for the prevention and control of drug addiction. The law also indicated that addicts might be admitted to mental hygiene institutions or clinics in the following categories:

  1. Civilly committed arrested narcotic addicts;

  2. Voluntary admissions;

  3. Admissions via commitment as a condition of probation;

  4. Admissions on court certification.

The strength of this law was attenuated, however, by the fact that most addicts chose to go to jail rather than submit themselves to treatment. In 1966, this legislation was amended in the so-called Rockefeller Law which provided for addicts to be sentenced by the Court to the jurisdiction of the New York State Narcotics Control Commission for treatment over a three year,period in a state or a state-approved facility. This law went into effect on 1 April 1967.

Meanwhile in the early 1960s, other public and private programmes were initiated, some of them marked by innovative features, such as the establishment of workshops, half-way houses and therapeutic communities, the use of ex-addicts in the treatment of addicts and the use of narcotic and non-narcotic drugs to block heroin dependence.

New York State Narcotic Addiction Control Commission

This Commission set up by the Governor of New York State is responsible for implementing the new law which came into force in April 1967. In order to do this, it is aiming to provide 7,000 beds in the State of New York to deal with narcotic addicts who will be referred to hospital by the courts. The majority of these cases will be addicts from New York City. The Commission has only recently been set up and its budget is of the order of 80,000,000 dollars, but it is hoped that a good part of this will come from Federal Funds.

New York City Office of the Narcotics Co-ordinator

When Mayor Lindsey was appointed Mayor of New York, one of his actions was to enlarge the Office of the Narcotics Co-ordinator. Under the previous Mayor of New York this office was mainly concerned with keeping an account of all the facilities for treatment in the state of New York, and it came under the New York City Community Mental Health Board. The Office has now been increased in size and stature and the Narcotics Co-ordinator reports directly to the Mayor. Dr. Efren Ramirez who has taken over this department, had previously worked in Puerto Rico and his approach to narcotic addiction was based on the work of Maxwell Jones. He is endeavouring to provide a mass programme for the treatment of narcotics addiction by using unskilled and semi-skilled personnel. He has recruited a large number of ex-addicts who are no longer taking drugs and is training them to act as block workers. At the time I saw him he had taken about 230 onto his pay roll. This programme is in its earliest stages and it is impossible to assess how effective it will be. The main question about it at the moment is whether there is sufficient follow-up built into the programme to measure its effectiveness.

Dr. Ramirez was formerly Director of the Addiction Research Centre in Rio Piedras, Puerto Rico, and his programme there was based on the use of ex-addicts in reaching and treating the addict, even before the addict sought treatment himself. His view, which had increasing evidential support, was that the ex-addict, unlike the psychiatrist or social worker, would be accepted by addicts as one who knew and understood both the jargon and the motivations of the addicts' subculture. Thus he could more effectively reach the addict and compel him to face his problems. In New York City he has now developed an elaborately phased programme in which addicts similarly get involved either while still addicted on the street or when they are in prison. They then attend group sessions and gradually work their way through phases of increasing responsibility and increasing involvement in the contacting and treating of other addicts. In the early stages, the few full graduates of this programme were mostly employed by the programme as helpers for new patients.

Narcotics Register Project

This Project has been in action for about two years now and the aim is to compile a register of all narcotic addicts in New York City. Reports now go to the register from the courts, parole officers, hospitals, private physicians and from the Federal Bureau of Narcotics and these are collated by this department. This is the first comprehensive attempt to make an accurate assessment of the number of narcotic addicts, and their social and economic backgrounds. It is expected that the project will last for another one or two years by which time a large amount of useful information will be available.

Details of Project

"The Narcotics Register Project is an outgrowth of interest in the register concept within the New York City Department of Health. In essence, a register is a roster of cases of a particular disease or problem in which mechanisms exist for systematic linkage of reports of contact with the case from all treatment service programmes within a designated area. The register is a tool for the development of estimates of total incidence and total prevalence from data available on the reported population. Case registers have been explored as epidemiologic and case management tools in a number of public health areas including tuberculosis, venereal disease, cancer, rheumatic fever and blindness.

In the mental health field a number of community psychiatric case registers have been compiled and used for a sufficiently long period to provide valuable experience in problems of reporting, data storage and data analysis. Computer applications, especially in this latter field, have provided the Narcotics Register with much useful information. The Narcotics Register Project is seen as having the potential to provide the types of data presently needed to define the scope of the narcotics problem and to provide a sound methodology for specialized epidemiologic, demographic and sociological research.

Legal background

The reporting of " habitual abusers of narcotic drugs" by physicians was made obligatory in 1952 by the New York State Department of Health as a preliminary step towards assessing the seriousness of the narcotic addiction problems in New York State. The New York City Department of Health acted as the agent of the State in receiving these reports and in transmitting them to the New York State Department of Health. As has been noted, in 1962 the "Metcalf Bill' was passed by the New York State Legislature which concerned many aspects of drug addiction. One important provision involved the option, for certain individuals arrested for narcotic possession or other related criminal offences to "request consideration by the court for civil commitment to a hospital facility, as a narcotic addict ". This legislation spurred the establishment of medical examination procedures, especially for males, within the courts which substantially added to the volume of addict reports received by the then embryonic register. In 1963 two amendments to the New York City Health Code contributed substantially to the increased and improved reporting of addicts within the City. The section requiring reporting of addiction, which under the old Public Health Law required reporting only by physicians was amended to read "... Cases of narcotic addiction as prescribed shall also be made by a person in charge of a correctional institution, social agency or any other person who has knowledge of or gives care to a narcotic addict ". One of the most recent legislative efforts, relevant to narcotic addiction, was enacted in March 1966. It involved many aspects of the problem and allocated new money for treatment, research and preventive educational programmes. The Local Police Department, which apprehends persons who violate the penal laws of New York State and New York City, is a major source of reports of addicted persons. Numerous sections of the penal law cover such offences as possession of drugs, in which, within limits, the quantity of drugs confiscated, determines the seriousness of the charge.

Development of the reporting system

Historically, under a rudimentary initial reporting system the Health Department annually received 3,000 to 4,000 reports of patients with narcotic drug addiction in the period 1953 through 1962. In 1963, when preliminary steps to develop a register were begun and when reporting liability was extended to include non-physician reporting, the figure jumped to 13,000 reports. This increased to 15,000 in 1964 and 21,000 in 1965. In 1966, the initial year of the operation of the Narcotics Register Project, 48,000 reports were received. Not all these reports represented different persons. It was estimated that there were 35,000 separate names in the register. With respect to incidence, about 9,000 new cases were reported in 1963 and 7,400 in 1964. In time, given reasonably complete reporting and no change in the underlying factors giving rise to drug addiction, this number should level off at some point reflecting that portion of the addicts who come to public attention. The large increase in reported cases from 1965 to 1966 was primarily a reflection of the steps taken by the register to increase the reporting. The register is now receiving routine reports of all admissions to the Manhattan General Hospital, which admits approximately 8,000 patients annually for treatment of drug dependence. In addition, the New York City Police Department has approved the notification to the register of all records of arrests of addicts and drug users; this adds approximately 18,000 reports to the register every year. Routine reporting from the New York City Department of Corrections continues to give the register about 10,000 reports each year.

These reports become part of a file for each addict reported, and contain such basic information as name or names, birthdate, birthplace, place of residence, sex, ethnic group and drugs of abuse. Frequently, additional information is available on education, religion, occupation, hair and eye colour and next of kin, depending upon the variety of reporting forms available for the individual addict. The register is involved in the various difficulties encountered in "person matching ". These "person matching" procedures are necessary to provide an unduplicated count of the addict population.

Information available through the Narcotics Register will provide data useful in the following areas:

  1. Determination of the basic epidemiologic characteristics of the currently reported narcotic addict population, such as age, sex, residence, ethnic group, education, occupation, drugs of abuse;

  2. It will illuminate trends in the reported addict population concerning epidemiologic and demographic variables;

  3. It will lead to the development of statistics on "newly" reported cases each year who represent individuals never previously reported to the register, and this will eventually emerge as the incidence of addiction; the register as a whole will provide an estimate of the prevalence of addiction;

  4. By permitting the development of longitudinal analyses of the register files it will uncover estimates of probability of recurrent reporting, probability of mortality for age or race specific cohorts; and the patterns of agency utilization and reporting;

  5. It will also allow for the evaluation of the programmes and research undertaken in the community by throwing up data for comparative analysis of " cure" rates, recidivism, hospital experience, and the criminality of the patients under various service programmes.

To summarize these arrangements:

  1. Reporting of habitual users of narcotic drugs in New York City has been supported by legislative action in the City and state.

  2. The register concept, already applied to other public health and mental health problems, is being developed and explored, by the New York City Health Department, for application to the narcotic addiction problem.

  1. The Narcotics Register will provide a wide range of necessary and useful descriptive and longitudinal data for public health planning and treatment programmes.

New York Division of Parole

This department deals with prisoners who are paroled (i.e. have left prison on licence before the end of their sentence). While they are on parole they are the responsibility of a parole officer; the latter can refer a person back to prison if he feels he is likely to get into further trouble, or has already done so. In the past, narcotic addicts who had been paroled automatically went back to prison if they violated their parole by taking drugs on any occasion. More recently a new approach has been tried whereby all the narcotic addicts are assigned to a particular parole officer who has a lower case load than is normal. He has wide discretion as to how he will treat narcotic addicts. If they relapse and start taking narcotics again, he may either do nothing if the person is at work, or if he feels it necessary, he may refer him or her to one of the hospitals, such as the Manhattan General Hospital, to be taken off drugs again, or if he feels that nothing further can be done he may return the case to prison. This is one of the few departments where there has been adequate follow-up and the results of this approach to treatment have been promising. (Programmes both in New York and Philadelphia utilize specially supervised and trained parole officers with small case loads in the treatment of addicts released from prison. It is usually arranged to have contact established between the addict and the parole officer, before the prisoner is released on parole.)

New York State Parole Drug Experiment

In 1960 the special narcotic project of the New York State Division of Parole, assessed the results of a three year study. The data revealed that during the period between 1 November 1956 and 31 October 1959, a total of 344 parolees with a history of narcotic addiction had been under the supervision of a specially trained group of parole officers in the narcotic project. Of this number 119 offenders, or 35 per cent, had not been declared delinquent again for any reason what-soever, including drug offences. There were 36 parolees who although declared delinquent for other reasons, such as technical violation of parole or arrest by the police for new charges, nevertheless had never reverted to drug usage during that period of supervision. In other words 45 per cent abstained from drugs while under supervision. A further study was made in December 1962, three years and two months after the original investigation. The number of successful adjustments dropped from 119 to 83 or from 35 to 24 per cent. A further follow-up showed that after discharge from parole, those who relapsed began using drugs at approximately six months (range 0 to 24 months) after the end of parole.

Greenwich House Counselling Center

The Greenwich House Counselling Center was started in 1963, to fill a void in the existing treatment services for drug addicts, as a professionally staffed community based counselling service, operating in a non-governmental setting. It was set up on an experimental basis by the National Institutes for Mental Health. It was originally designed to give advice to addicts who lived in Greenwich Village, New York City, but it later accepted addicts from other neighbourhoods. The Center is now financed by the State of New York. No specific withdrawal treatment is practised and addicts are not expected to be off drugs when they attend this centre. If they wish to be taken off drugs they are referred on to another facility.

The principal method of treatment is the individual counselling of drug users and their families, which is made to conform as far as possible to their specific needs. A simplified intake procedure which does away with extensive initial evaluations makes it possible for the counsellors to become promptly involved in the addicts' current problems. The attitude of the staff is non-authoritarian with no pressure put on patients to abstain from drug use, or to seek employment. They are encouraged to keep regular appointments, even when intoxicated. Other services include group therapy of patients and families, a limited group work programme and referrals to appropriate agencies for medical and financial assistance.

A large number of drug users referred by many sources have sought treatment at the Center. More than 80 per cent of them use heroin predominantly, the other drugs used include marijuana, amphetamines, barbiturates, glutethimide and various hallucinogens. Most of the patients so far seen were chronic users who were deeply involved in drug use and associated activities. They had the characteristics of addicts described by other authors (a low socio-economic status, disrupted family background, evidence of inadequate social and vocational functioning, and disturbed personalities). They had been arrested frequently and had tried many times to stop using drugs. The minority, who were less involved in drug use were socially and psychologically a more heterogeneous group. The principal task was seen as getting them committed to a treatment experience so that therapists could have an impact on their lives. The attrition rate was high, 50 per cent being seen three times or less. When they did come regularly treatment was interrupted by frequent hospitalizations and incarcerations.

On the positive side they seemed more willing to discuss their problems with the Counselling Center than with hospitals or in other settings where there is an element of authority.

The first practical conclusion from the Center's experience is that it is possible to operate a treatment service for addicts in the same physical setting where there are non-addicts.

Bellevue Hospital

Bellevue Hospital is the observation ward for all of the City of New York and a very large number of people are admitted there for short periods. It has no specific programme for the treatment of drug addiction, but a large number of patients are admitted annually with psychoses following the taking of LSD (or cocaine psychoses or amphetamine psychoses). Patients who require further treatment are transferred on to one of the regular State Hospitals. Dr. Donald Louria has much experience of the physical complications seen in heroin addiction, which are identical with those seen in England.

Manhattan General Hospital

This is a hospital situated in downtown Manhattan which has about 600 beds of which 400 are allocated for the treatment of narcotic addicts. The addict admission rate to this hospital averages 28 admissions a day and has been as high as 45 admissions on one day. The majority of patients admitted stay either for about a day when they discharge themselves against advice or for between two to three weeks when detoxification programmes have been finished; at this stage they generally discharge themselves. A few patients stay on for longer and endeavour to complete the fuller programme of rehabilitation which is offered. Recently a methadone maintenance programme has been started in this hospital and a small number of selected patients are being treated with long-term oral methadone.

Pilgrim State Hospital

This is a large mental hospital with about 15,000 beds in the State of New York which serves New York City. A large number of addicts are admitted every year to the hospital and treated in the usual way, i.e. detoxification in the first instance followed by such psychiatric measures as rehabilitation, occupational and similar methods of treatment.

I visited one of the new units which has been developed under the new comprehensive New York programme by which addicts are committed for treatment under the civil commitment procedures. The unit was well run but it was difficult to evaluate its effectiveness at present, since no patient had yet been discharged, as it had only been open for about five months. As the general plan was that patients should remain for periods of up to nine months before being discharged on parole, it was obviously far too soon to assess the effectiveness of what was happening.

Manhattan State Hospital

This hospital is run by the State of New York and is a mental hospital which has wards assigned for the treatment of drug addicts, the majority of whom come from New York City.

Patients in the hospital were treated according to established methods. They worked in the hospital premises, but unlike similar patients in Britain, they did not go out from the hospital to work. There are extensive laboratory facilities at the hospital and these are run by Cornell University.

Rockefeller Institute Hospital

At this institution, Dr. Vincent Dole runs a programme of methadone maintenance which has now been in action for four years. The majority of patients in the programme, however, have not followed it for much more than one or two years. The main difference between this programme and other programmes is that the follow-up of the patients is more thorough. All receive their oral methadone daily, and must undergo a daily urine test to see whether they are taking heroin or other narcotic or stimulant drugs. Weekly reports are made on each patient in the programme as to social adjustment, as to whether he is working and whether or not he has come before the courts again. So far, 90 per cent of all patients in this programme have been followed up. (Another innovation is an Evaluation Committee to which Dr. Dole has invited people who were critical of the methadone maintenance programme, and who have pursued other modes of treatment.) Many of the patients in this programme are first treated at the Harlem Hospital under Dr. Robinson and later are referred to one of the out-patient follow-up clinics, two of which have been set up in Harlem. One of the striking things about the methadone maintenance programme is that many of the aides working in the department are people who themselves have come into the programme earlier and in many ways are similar to members of Alcoholics Anonymous, in that they are anxious to button-hole any one on any occasion to tell them of the value of the programme for themselves and other people.

Metropolitan Hospital

The Psychiatric Department in this hospital is part of the New York Medical College Medical School. At the hospital, narcotic addicts are treated in the usual ways by detoxification and there is a programme for methadone maintenance and cyclazocine is also used.

New York, Flower and Fifth Hospital

At this hospital Dr. Max Fink was working with heroin, cyclazocine and naloxone (another and newer narcotic antagonist) studying the effects of these drugs and combinations of these drugs on the electroencephalogram using automatic analysis and computer print out. His aim was to measure the effects of the drugs, and for how long the block antagonist remained effective.

Lexington (U.S. P.H.S. Hospital)

The programmes include detoxification, a stable controlled environment, some access to individual and group psychotherapy, education and vocational rehabilitation programmes, and industrial and recreational therapy. The results of this programme both for voluntary addict admissions (who are supposed to stay five months but on the average stay about six weeks) or for prisoner patients are relatively poor. About 10 per cent are drug free for the first year after release. Several follow-up studies of Lexington patients point to the need for adequate care in the community following discharge. The hospital had recently been taken over and was being directly run by the National Institutes of Mental Health rather than as a separate institution under the U.S. Public Health Service. This meant that it had now become in effect a purely research organization rather than a service organization, with an addiction research unit in it. This re-organization had raised some problems especially as regards the availability of clinical material for testing analgesics in man. It was expected that the problem would be overcome, but not without difficulty.

Addiction Research Center

The National Institute of Mental Health Addiction Research Center at Lexington was established under the same law which took over the Lexington hospital. The Center was responsible for investigations of the cause, treatment and prevention of drug addiction. The development of the new synthetic pain relieving drugs and the increasing incidence of barbiturate addiction have emphasized the need for further research in this field. The work at the Addiction Research Center may be divided into two areas.

  1. New drugs: investigations of the addiction producing properties of new pain relieving drugs is made and the Center serves as the clinical testing centre for both the Drug Addiction Committee of the National Research Council and the WHO Expert Committee on Dependence Producing Drugs.

  2. Psychological causes: fundamental types of investigations of the psychological causes of drug addiction and changes in physiology and in emotional reactions that follow administration of drugs are studied. The biochemical changes associated with addiction are also under investigation at the Center. The social science section of the Research Center conducts follow-up studies of ex-patients and analyses the records of the two narcotic hospitals, concerning admissions and discharges.

Illinois

The extent of drug abuse in Illinois is not known with certainty, although police records provide the basis for an estimate of approximately 7,000 to 9,000 narcotic addicts in the state. Illinois is believed to have the second or third most serious addiction problem in the United States. New York contains perhaps half of the nation's addict population while Illinois and California are ranked next, their addict populations being more or less equal.

The use of "hard" narcotics is primarily concentrated in the congested slums of Chicago and to a lesser extent in other urban areas of the state such as the East St. Louis area and Peoria.

In Chicago it is believed that the concentration of heroin users in slum areas is based on two factors:

  1. The tensions, frustrations and despair of poverty and racial discrimination create the motive to escape such unbearable reality; heroin is an accepted escape mechanism in the inner city. The slum dweller who turns to heroin would more likely if he lived in the suburbs turn to amphetamines, barbiturates or alcohol;

  1. The congested urban areas provide cover for an illegal distribution system, and heroin users must converge upon an area where there is a supply, and where they can have the protection and self-reinforcement of other users, and where the opportunity to support their addiction by petty criminal activity is greatest.

Effective law enforcement had sharply curtailed the availability of heroin in recent years. This restriction was believed to have been a factor in keeping the number of users from increasing. It had also substantially increased the cost of illegal narcotics. As a result, heroin sold in the Chicago area was significantly diluted or cut, often being sold in a combination of 98 per cent milksugar and only 2 per cent heroin. For this reason, physical symptoms of withdrawal were generally far less than they were several years ago. Another consequence has been a significant increase in users experimenting with different drugs taken in combination.

The cost of drug abuse in Illinois cannot be wholly calculated, but some of the economic effects are capable of some sort of measurement. In rough calculations it has been estimated that 25 per cent of the inmates of the state prison are addicts. The direct cost of addict imprisonment alone as reflected in the Department of Public Safety Budget, exceeds five million dollars each biennium. Law enforcement costs are also significant. The Illinois Division of Narcotic Control has a budget exceeding one million dollars biennially. Finally the cost to Illinois of crimes related to addiction is immense. Assuming there are at any given time 5,000 active heroin addicts in the state, each of whom must spend 25 dollars a day to support his addiction, this means that they must obtain 125,000 dollars each day for the purpose. Many women addicts are believed to turn to prostitution. Other addicts obtain drugs by participating in their distribution, but a large proportion is believed to finance its addiction by petty theft, selling the stolen goods at perhaps 25 per cent of their real value. Again making an estimate that there are 3,000 such addicts, the losses in petty thefts alone must exceed one hundred million dollars a year.

Until recently the approach to addiction in Illinois has been almost entirely to clamp down upon distribution. In 1957 and for a brief period thereafter, treatment clinics were maintained, but they were not a success. The major reason for their failure was that they were based on the premise that addicts were sufficiently self-motivated to seek help without external encouragement - a much too optimistic conclusion. Since 1959 the state has passed legislation for the civil commitment of addicts, but until recently the law was never used. The only real addiction facility in Illinois in recent years, however, has been the Chicago House of Correction (Bridewell). This is a twelve bed detoxification unit in the Andrew Cermak Hospital where treatment is in the form of short-term detoxification and there is no provision for follow-up care.

Narcotics Court

According to Judge Wendt of Chicago's Court 57 (Narcotics) some fifty million dollars is stolen in petty theft every year in greater Chicago, about seventy-five per cent of these crimes being committed by addicts. All drug arrests are channelled to Court 57. There are apparently 150 Federal agents, 24 state agents and 64 City agents dealing with narcotics cases. Greater Chicago with a population of six million is thought to have possibly eight thousand addicts. In the State of Illinois, the sale of heroin as a first offence draws a ten year to life sentence, and for a second offence the life sentence is mandatory.

Until recently there had been virtually no facilities in Chicago for the treatment of addicts and the only way that they could obtain withdrawal and detoxification was by being admitted to the local prison. This is now in the process of being changed and under Dr. Jerome Jaffe, a new programme is being instituted. If it is possible to carry this out as Dr. Jaffe hopes, it should be one of the more valuable programmes in the United States, in that Dr. Jaffe, who has done much work with methadone and cyclazocine has a pragmatic approach and wishes to try various methods of treatment and at the same time to evaluate their cost effectiveness. He proposes to have a cyclazocine, an oral methadone maintenance, a detoxification and a Daytop type programme, with a separate evaluation programme.

St. Leonard's House, Chicago

St. Leonard's House was a project staffed under the direction of the Reverend Bruce Wheeler, an Episcopalian, and with funds from the Office of Economic Opportunity, which was running a narcotics project. The primary aim of this agency since its founding in 1954 has been to assist ex-prisoners in their transition from being inmates in the prison community to being citizens in the free community. The aim has been developed through the use of a residence, 21 men at a time - 150 per year - employment assistance, counselling, and other forms of supportive activity. Through its total programme St. Leonard's House currently works with over 400 male and approximately 75 female ex-offenders per year. Of this group 25 per cent of the men and 75 per cent of the women are former drug addicts.

In addition St. Leonard's House has a reputation among the delinquent population of being a resource for help such that over the years there has been considerable contact between the staff of the agency and the using or active addict population.

St. Leonard's House then established a narcotics project in the Mile Square Federation Area on the west side of Chicago with the following objectives:

  1. To establish contact with, and to provide information, service, and referral for the solution of immediate problems, to four hundred addicts per year.

  2. To provide to half that number (200 addicts per year) selected out of the above group, orientation, preparation for, and development of a longer term programme of rehabilitation (including detoxification or withdrawal from physical dependence).

  3. To provide extended rehabilitative care after withdrawal to one hundred persons selected out of the above group.

  4. To train a limited number of ex-addicts, selected out of group C as rehabilitation workers to carry on portions of the programme and its expansion.

  5. To provide ancillary services to addicts, such as family counselling, medical and legal services.

  6. To promote, stimulate, and assist in the development of other treatment modalities in the Chicago area, including drug therapy and Daytop-like therapeutic communities.

  1. To secure laboratory facilities which provide thin-layer chromatography testing of urine samples for participants in the programme as well as in other programmes.

  2. To stimulate and assist other community agencies and resources to undertake rehabilitative work with addicts, and to initiate and participate in prevention programmes involving public education.

  3. To evaluate the project quantitatively and qualitatively in terms of the services offered and to develop a research design for the continuation of the project beyond the first year of operation.

This project was working closely in co-operation with Dr. Jerome Jaffe.

California

California Rehabilitation Center, Corona, Los Angeles

This treatment programme under the correction system of the state has been running for four years. All patients, even volunteers are committed, the former for 2 years, but patients with a criminal conviction for 7 years. The in-patient treatment programme is stated to be modelled on the Maxwell Jones "therapeutic community" concept with each consisting of 60 persons comprising the treatment unit. Daily group discussion meetings are held at which both current living problems and deeper matters are discussed. Emphasis is also given to increasing the association of the patients with responsibility for the programmes. Work therapy, school and vocational training are provided. The period spent by patients in the institute is relatively long, at least six months being required by law. The actual in-patient time before discharge on licence averaged 15 months for men and 11 months for women. The timing of release to the community is based on staff evaluation of each patient's growth and strength, and his ability to resume responsibility for his own behaviour. On return to the community, patients are intensively supervised by case workers with special training. These social workers have low case loads of about 30 patients each, including weekly group meetings and individual contacts with each patient at home or on the job. Nalline tests are given, both regularly and by surprise, for at least the first six months. Patients showing signs of relapse, either a return to drugs, heavy drinking or inability to hold jobs or other delinquent activity, return to Corona for further treatment. A half-way house programme is being developed. In December 1965-there were 1,672 males and 268 females in the Center. In addition 2,578 men and 665 women had been returned to the Center for further treatment. Only about 33 per cent of released patients were able to exist one year in the community and remain free of drugs. Of those remitted for further treatment only a half had resumed the abuse of heroin.

The work of Dr. David Smith, San Francisco General Hospital, Immediate Psychiatric Aid and Referral Center

This is the only facility in San Francisco giving methadone withdrawal for opiate addiction. This type of treatment is limited by law to seven days, and only six beds were available. There were a large number of problems in misuse of stimulants such as amphetamine, L.S.D., narcotics such as heroin, sedatives, alcohol, and barbiturates. The unit was grossly inadequate for its case load and over crowded. When Dr. Smith set up a free medical clinic in the Haight Ashbury area, he found there were ten thousand referrals in the first three months. Most of these were minor medical problems, but there were only very limited facilities to refer people to hospital except in cases of serious illness, hepatitis by itself, for example, was insufficient cause. It was thought that there might be ten thousand regular heavy users of L.S.D. in San Francisco. Seven hundred and fifty such people who had attended the Haight Ashbury clinic had been interviewed in depth, and the main finding that emerged was that of multiple drug use.

San Francisco: The work of Dr. Herbert Blumer

Dr. Blumer and his associates have recently completed a report on the extent of juvenile drug use in Oakland. This is one of the very few valuable surveys in this field. It gives much information about why young people use drugs and what they think about drugs and the effects drugs have on them. The main finding of this report is to the effect that cannabis use is a normal social activity in many groups. The survey ("The World of Youthful Drug Use ") gave one of the fullest available descriptions of the social conditions fostering the marijuana habit in Oakland, California. The investigators obtained the confidence of youngsters, mostly Negro and Mexican, by providing them with club amenities without strings. The youngsters were firm in their conviction, based on their own experience, that the use of such drugs as marijuana, resulted in harmless pleasure and increased conviviality: that it did not lead to violence or madness, could be regulated, did not lead to addiction and was less harmful than alcohol. They were not interested in being helped to abstain from marijuana and they cited case after case of individuals known to them, who had not suffered deterioration in health, in school achievement, in athletics or in their career as a result of their habit of smoking marijuana. Any boy who took the drug in excess was considered by the rest to have a weak personality.

Dr. Blumer and his group, recognized four patterns of use and users among these youths and the latter themselves recognized four types, known by slang names. Initiation into marijuana smoking in this group usually began in the desire to emulate older boys. The Oakland investigators firmly rejected the usual assumption that those who took to the habit were mainly influenced by emotional disturbances and social stresses. Their observations did not support the explanation which regards marijuana use as an effort to escape from reality or to give vent to an underlying hatred of organized society. They concluded "Induction into drug use is a developing experience that depends on access to drugs, acceptance by drug-using associates, and the kinds of image that youngsters have of drugs." So far from reality, marijuana users are held to be making a positive effort to be in the mainstream of their set. The investigators likewise rejected the notion of a steady progression from marijuana to crime and opiate addiction. (These may occur, but most users steered away from such courses.) The summary conclusion by the Oakland observers was unequivocal: "Youthful drug use in Oakland is an appreciably extensive and deeply rooted practice, lodged primarily in the lower strata but currently expanding to middle and upper-class strata. It is woven into a round of adolescent life as a collective practice.., and it is buttressed by a body of justifying beliefs and convictions. It involves a repertoire of practical knowledge and incorporates a body of precautions and protections against apprehension or arrest. Drug use constitutes for the users a natural way of life and does not represent a pathological phenomenon."

CANADA

Drug addiction in British Columbia

Drug addiction started in British Columbia when a large number of Chinese labourers were brought into Canada through the port of Vancouver around the turn of the century. They had been recruited to work on various construction projects and having been opium smokers in China, they were allowed to continue this activity. The extent of use of this narcotic drug could be measured at the time. In 1884, 60,000 pounds of opium valued at 200,000 dollars were imported and at that time two opium processing factories were opened, one in the city of Westminster and the other in the city of Victoria. Following the original Chinese narcotic users, an increasing number of native born Canadians started to use drugs in a similar way.

At the beginning of the twentieth century, the Customs collected a 20 per cent ad valorem tax on the importation of raw opium, until the year 1907. In 1908 Parliament passed the first opium act, known as the Narcotics Control Act.

Between 1908 and 1954, little appears to have been done in the way of treatment or rehabilitation, apart from general police action. An excellent study was carried out in 1954 by Dr. G. H. Stevenson of the University of British Columbia, but unfortunately it has not yet been published. Following the Stevenson report, the Narcotic Addiction Foundation of British Columbia was formed. This Foundation, one of the early pioneers, continues to play a leading role in the field of mood changing drugs and is also concerned with research. The Foundation now consists of an out-patient clinic and a residence treatment unit for in-patients. There is a hundred per cent bed occupancy in the 11 bed residence treatment unit, and 175 addicts are seen every month at the out-patient clinic.

Of 3,500 known addicts in Canada, roughly 2,000 are to be found in British Columbia.

A very interesting development in Vancouver is that since February 1963 a pilot programme of "prolonged withdrawal" has been in operation. This is essentially a methadone maintenance programme, but it is called "prolonged withdrawal ", apparently because the notion of indefinite continuance of methadone maintenance runs counter to currently accepted views of how best to treat addicts. It is interesting that in Canada there is a fair amount of influence in the clinical treatment of patients from the authorities in Ottawa, and it would not have been easy for a doctor to prescribe over a long period of time, considerably larger doses of methadone had he thought this necessary. (Again this appeared to be another example of the problems that arise when the enforcement agencies insist on a particular line of conduct when there is no evidence that what they are insisting on is of any value at all, or will do harm or good. This reliance on emotionally determined views of what is correct treatment in place of a scientific assessment of the advantages and disadvantages of various types of treatment is something it would be very desirable to avoid in the United Kingdom. If one does not do this, one eventually reaches the extraordinary situation that it is impossible to try out a particular kind of treatment even though there is no evidence to show that it might not be extremely beneficial.)

Vancouver: The Narcotic Addiction Research Foundation

Work at this Foundation in Vancouver is based on using long term methadone maintenance. Due to the Federal laws, up to the present no more than thirty milligrammes per day has been used. A Federal penitentiary has been set up at Matsqui which is somewhat similar to the California Rehabilitation Centre. There is also treatment at Oakalla Prison Farm. In Vancouver, there has recently been an increasing amount of misuse of L.S.D. and amphetamines.

Toronto: The Narcotic Addiction and Alcoholism Research Foundation

This Foundation which was originally started for research in alcoholism has now broadened its scope and is now much concerned with problems of narcotic addiction as well. The annual budget which comes from the state of Ontario has risen from one to seven million dollars per annum and there is a suggestion that the future budget may attain twenty million dollars per annum. It has been suggested that the Foundation should take over all the treatment of alcoholism and addiction in the province and hence the need for an increase in funds. The Foundation itself doubts if it would be a good idea to separate alcoholism and drug addiction services from other medical services. It also believes that its function should be to set up pilot treatment projects rather than provide over-all service facilities. The Foundation is concerned with research, has an active library and abstracting service and many publications have come from this centre. It also runs an active education department. Up to the present, apart from setting up pilot projects for treatment it has been concerned with evaluation of the effectiveness of treatment in Toronto.

6. SUMMARY

To very briefly summarize my main impressions of what is happening in the United States at present in the field of drug dependence, the first and most important impression that I received was of a great increase in interest in the problem of drug addiction at every level, medical, legal, sociological, criminological. Much thought is being given to different possible programmes for dealing with it, and this is very noticeable as far as treatment is concerned. There are a large number of different types of approach to treatment and all are being currently tried out, most of which had been developed only in the last decade. This again is particularly the case in California and New York, where very large sums of money are being spent in attempts to rehabilitate addicts. The one criticism that one could have of this wealth of activity, was that it is perhaps not sufficiently critical, and that not all of the new programmes being tried have been, or are being, properly evaluated. It certainly appeared to me that a large amount of the money and enthusiasm was possibly not being used to the best advantage, and that more consideration could have been given to studying the effectiveness and cost of various programmes.

A second point that I think is very well worth making, was that I was impressed at the number of unnecessary difficulties that have been encountered in the United States and Canada from very restrictive legislation. Much of the law appears ineffective for dealing with the problems, and it has handicapped people who wished to try alternative approaches to treatment. The heroin maintenance programme, though it has been attempted on an experimental scale, is highly controversial at present in the United States. In the author's view, the problem of heroin addiction can be approached from various angles and it would be wrong if the United Kingdom were to take a dogmatic view in favour of one approach rather than another, since final conclusions on any one approach would still be premature. Now that new treatment centres have been established in Britain, their work should be assessed realistically and if there were to be a setback this should not provide sufficient reason for immediate imposition of repressive or draconian legislation. In this respect, I am inclined to think that the United States line has been somewhat impatient, though of course the problem with which it is bedevilled is much greater than in the United Kingdom.

A third difference I noticed in the United States when making comparisons with Britain, is that in the U.S.A. there is a tendency to aim at being all successful in the treatment of various kinds of addiction, and less thought is given to the problem of dealing with those who are not going to respond to treatment. There seems to be little concern for patients who are unlikely to be cured. In fact in practice this tends to be left to penal institutions, which may be an expensive way of containing the problem. It would be interesting, if it were possible, in New York for example, to try a controlled trial of prescribing heroin for chronic recidivist narcotic addicts as is to be done in Great Britain and to compare the cost of this programme with the cost of imprisonment (and the indirect costs of theft to obtain heroin illegally). Unfortunately, owing to strongly held views it would not be possible to carry out such a study at present. The final thought I have brought back from the United States is that since studies of this type cannot be carried out in the United States, they should definitely be carried out in a careful way in the United Kingdom, so that the effects of prescribing heroin as a method of treatment can be finally evaluated in a cool and scientific manner.

Reports quoted

President's Commission: The Challenge of Crime in a Free Society (Task Force report on narcotic abuse).

Treasury Department (Bureau of Narcotics). Prescribing and dispensing of narcotics under Harrison Narcotic Law, Pamphlet 56, revised 1963, Washington.

E. Ramirez A new programme to combat drug addiction in New York City.

F. Kavaler Menachem. The Narcotic Register Project: early development.

M.H. Diskind. 1. Recent developments in the treatment of paroled offenders addicted to narcotic drugs.

  1. A second look at the New York State Parole Drug experiment.

R. Osnos and D. Laskowitz. "A counselling centre for drug addicts." ( Bull. Narc. Vol. XVIII, No. 4).

Report of the Illinois Narcotic Advisory Council to the Seventyfifth General Assembly (1967).

St. Leonard's Comprehensive Community Oriented Programme for the rehabilitation of drug users (Chicago).

R. W. Wood. Civil Narcotics Programme A five year progress report..

Third Annual Report of the Narcotics Rehabilitation Advisory Committee, California 1967.

H. Blumer. The world of youthful drug use. A.D.D. centre project. Final report.

G. Stevenson. Drug Addiction in British Columbia (MS) University of British Columbia.